Evolving the OCM: OCM 2.0 & Beyond

WebinarTuesday, January 9, 2018

• Kavita Patel, MD, MS, Tuple Health

• Basit Chaudhry, MD, PhD

• Ted Okon, Community Oncology Alliance

• Bo Gamble, Community Oncology Alliance

Speakers

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Housekeeping1. This webinar is being recorded and will be posted on the COA website later this

week.

2. Q&A will take place at the END of the webinar. Please submit questions via the

Zoom platform – look for the Q&A button of your screen.

“OCM 2.0”The Journey Ahead

Kavita Patel, MD, MSTuple Health

▪Meaningful alignment to expand the vision of value-based oncology care

▪ Preservation of options for patients to experience high quality care in a variety of settings

▪ Better care coordination

▪ Enhanced quality for all patients

▪ Inclusion of innovation and clinical transformation-flexibility and rigorous standards

The Grand Vision

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▪ Interviews with:

– Patient Groups

– Providers

– Payers/Employers

– Federal/State/Local Officials

▪ 2016 COA Payer Summit

▪ 2016 COA Annual Meeting

▪ 2017 COA State of the Union

▪ 2017 COA Payer Summit

▪ Focus groups

▪ Thought Leader Input: Dr. Bruce Gould, Dr. Mark Fendrick

▪ Literature Review

How We Developed OCM 2.0

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OCM 1.0 OCM 2.0 OCM 3.0 OCM 4.0

SCOPE

Episodic payment model for

patients undergoing

chemotherapy

Comprehensive oncology

medical home for patients

under active therapy and/or

active surveillance

Upfront financial risk for care of

patients undergoing active

therapy and /or active

surveillance

Population Based Capitated

Payment for patients

undergoing active therapy

and/or active surveillance

TRIGGER

Administration of

chemotherapy, oral or

physician-administered

Administration of

chemotherapy, oral or physician

administered

Diagnosis of cancer with

primary management by

medical oncologists

Screening and diagnosis of

cancer regardless of primary

management

ATTRIBUTIONPatients attributed to the

practice

Patients attributed to the

practice

Patients attributed to the

practice

Patients attributed to the

practice

PAYMENT METHODOLOGY

Monthly enhanced fees with

shared savings after a discount

applied

Monthly care coordination fees

with first dollar shared savings

Up front risk adjusted payment

with potential for bonus if below

cost targets

Capitated population based

payment

FINANCIAL RISKInitial upside with transition to

downside financial risk

Initial upside with transition to

downside riskInitial downside risk Capitated

QUALITY MEASURESClaims based and practice

reported

Reflective of population served-

also drawn from combination of

claims and practice reporting

Reflective of population served-

drawn from claims, practice and

patient reporting

Reflective of population served

drawn from claims, practice and

patient reporting

PHYSICIAN ADMINISTERED

DRUGSNo change in reimbursement No change

Some drugs in a value based

arrangement

Drug payments included in

capitated payment

ORAL DRUGS Included

Included with provision for

complete claims data along with

VBID component

Included with a VBID

componentIncluded with capitated payment

CARE NAVIGATION AND

COORDINATONPart of practice requirements Part of practice requirements Part of practice requirements No specific requirements

EFFICIENCY MEASURES

(time spent in direct clinical

care)

None Included Included Included

PATIENT ENGAGEMENT Minimal awareness Active shared decision-makingShared decision-making and

VBID for consumers

Beneficiary engagement

included potentially component

of savings

RISK ADJUSTMENT HCC Based HCC Based HCC plus additional factors

Focusing on OCM 2.0

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▪What we have learned: Cancer care is much more than active chemotherapy; payers,

providers and patients want to have comprehensive cancer care that begins with

prevention and runs all the way through diagnosis, treatment and survivorship

▪ Patients: want to know that their care is always coordinated and not interrupted because

of arbitrary definitions

▪ Providers: want to deliver high quality care and ensure that savings generated are

returned back to clinicians; want to also know that they are primarily responsible for care

provided

▪ Payers: want to offer high quality, competitively priced cancer care

▪OCM 2.0 elements:

– Inclusion once diagnosis is confirmed and management is primarily managed by a medical

oncologist

Episode/Trigger Definition

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▪ Patients should be attributed to a physician who delivers the plurality of their care

▪ Patients: want to know that they have one physician coordinating their care

▪ Providers: want to be acknowledged for work and efforts to coordinate care during

the difficult cancer journey

▪ Payers: Practice level attribution is much more practical

▪OCM 2.0 Elements

– Physician level attribution where plurality of services serve as definition of which physician in

a calendar year is attributed to the patient once treatment begins; there will be cases

where potentially a primary care physician or surgeon might then be attributed, but those

cases can be excluded

Attribution Elements

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▪What we have learned: Patients must be included in clinical trials where appropriate.

Novel therapies must be offered in a balance with consideration for cost; OCM 1.0

adjusts for novel therapy inclusion partially; clinical trial patients are generally excluded

▪ Patients: want access to best information and innovative therapies

▪ Providers: do not want to be placed in between the cost of drugs and their patients

▪ Payers: want to find ways to mitigate growing costs of innovation while offering highest

quality access to patients

▪OCM 2.0 Elements:

– Inclusion of clinical trial patients

– Ongoing work with providers to define how to include novel therapies and how

best to determine opportunities for cost savings while not penalizing providers

for appropriately prescribing medications

Innovation

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▪What we have learned: data must be two ways and as close to real time as possible;

accountability must incorporate relevant cost and quality measures and the standard risk

adjustment methods need to be modified to acknowledge the complexity of cancer care

▪ Patients: trust their providers but are definitely interested in having access to quality of

care metrics that can help them make decisions around cancer care

▪ Providers: want metrics that are relevant to their population and do not place undue

burdens on their practices, thus detracting from clinical care

▪ Payers: want to offer value-based contracts that balance financial rewards with measures

of accountability, incorporating clinical and financial risk

▪OCM 2.0 Elements

▪ Build on existing measures sets

▪ Identify measures that are relevant to practices and have significant volume

▪ Advance work with IT vendors to ensure data integrity, measurement capability, etc.

Metrics/Accountability

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▪OCM 2.0 Elements

– Transparent claims data availability in real time

– Risk adjustment that incorporates staging and relevant clinical information, socioeconomic

status, etc.

– Quality measures relevant to practitioners with clear inclusion and exclusion criteria with

open source data extraction that is adopted by all EHR vendors

– Acknowledgment of practices that are QOPI, COC, NCQA certified

– Acknowledgement of QCDR participation

– Financial risk for quality/performance measures

Metrics/Accountability (Continued)

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▪ Collaborative effort for a NEW OMH:

– American Society of Clinical Oncology (ASCO)

–Community Oncology Alliance (COA)

– Innovative Oncology Business Solutions (IOBS)

– National Committee for Quality Assurance (NCQA)

• Committed to improving the following areas for oncology:

– Care models

– Quality measurement

– Quality improvement

– Payment models

OCM 2.0 and OMH

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▪ Standards

– 7 main competencies

– Minimal and optional requirements for each

– Minimal total score is required

– Relevant and practical

– Describes what is required – NOT how to achieve

• Measures

– Limited set

– Relevant and practical

– Gather AND report

– Automatic reporting

– Evidence of completed requirements

• More details should be available early Spring 2018

OMH – Standards and Measures

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▪What we have learned: keeping it simple is best when it comes to the financial

elements; ensure financial stability while offering greater potential for upside savings

and a limited downside risk

▪ Patients: do not want OCM 2.0 to increase their copays or out of pocket costs; would,

in fact, want the opposite

▪ Providers: interested in taking downside financial risk with limits on the maximum or

some form of stop loss insurance/reinsurance

▪ Payers: Want to develop value based contracts that include incentives for better care

while also incorporating some element of financial risk around cost of care

▪OCM 2.0 Elements:

– PMPM + shared savings…but with straightforward methodology that is easy to

reproduce

– Limited financial downside risk

Financial Design

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▪ Inclusion of oral meds

▪ Inclusion of claims data in a timely manner (particularly 3rd party plans, PBMs, etc)

▪ Incorporation of concepts related to VBID

– Goal would be to identify discrete treatment regimens that do not offer any additional value

or could even pose potential risks to patients

– Goal: consensus, evidence-driven benefit design with element of clinical nuance

– E.g. Tarciva in EGFR+ in patients with no response after 3 months

Drugs

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• Potential VBID idea for Drugs:

– Eliminate copays for oral chemotherapeutics

– Emerging data illustrating lack of adherence at higher copay rates:

• Overall 18% abandonment rate, with higher rates in greater OOP categories:

• 10.0% for ≤ $10 group

• 13.5% for $50.01 to $100 group

• 31.7% for $100.01 to $500 group, 41.0% for $500.01 to $2,000 group

• 49.4% for > $2,000 group

• Armstrong et al. Journal of Clinical Oncology - published online before print December

20, 2017

Additional VBID Ideas

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▪ Start with certain cancers only? Dealing with issues of volume

▪ How to incorporate novel therapies

▪ Lessons from OCM that serve as important caveats:

▪ Transformation is hard and costly (not just infrastructure dollars, but labor)

▪ Inclusion of almost all cancers may not be best initial approach

▪ Novel therapy adjustment and robust risk adjustment key...but how?

▪Multi-payer participation

What are sensitive touchpoints?

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Potential OCM 2.0 Model

SCOPE Comprehensive oncology medical home for patients under active therapy and/or active surveillance

TRIGGER Administration of chemotherapy, oral or physician administered

ATTRIBUTION Patients attributed to the practice

PAYMENT METHODOLOGY Monthly care coordination fees with first dollar shared savings

FINANCIAL RISK Initial upside with transition to downside risk

QUALITY MEASURES Reflective of population served- also drawn from combination of claims and practice reporting

PHYSICIAN ADMINISTERED DRUGS No change

ORAL DRUGSIncluded with provision for complete claims data along with reduction/elimination of copays for oral

chemotherapeutics

CARE NAVIGATION AND COORDINATON Part of practice requirements

EFFICIENCY MEASURES (time spent in

direct clinical care)Included

PATIENT ENGAGEMENT Active shared decision-making

RISK ADJUSTMENT HCC Based

The Journey: Looking Back and Looking Forward

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Questions?

Use the Questions & Answer (Q&A) button in Zoom to ask a question!(Look at the top or bottom of your screen.)

Thank you!Learn more about COA, the OCM 2.0, and more at www.CommunityOncology.org• Be sure to sign up for our emails and newsletters for the latest updates!

Continue the conversation at the 2018 Community Oncology Conference taking place

April 12-13 outside of Washington, DC.• Featuring OCM panels and the eighth Payer Exchange Summit.

• Register at www.COAConference.org